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sanchez_ca

VIEWS: 15 PAGES: 2

									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Sanchez, Igleserio Age/Sex: 57/M Address: 2201 G.Tuazon St. Sampaloc Manila Date of admission: August 26, 2007 Admitting Diagnosis: Acute Coronary Syndrome prob unstable angina, high risk CAD, HCVD, Anterolateral wall Ischemia, NSR, E DM type 2 Residents in charge: Drs.Dalanon/Gutierrez/Gregorio CIC: Palay/Rentillo/Roxas

Hospital #: 1727247

Clinical Abstract This is a case of a 57 year-old male who came in to IM-ER due to dyspnea History of Present Illness Patient was previously admitted at Ospital ng Sampaloc due to Heart Failure. Few hrs PTA, patient was apparently well he developed sudden onset of difficulty of breathing not related to effort and not relieved by rest. No cough, no colds. He was then diagnosed with ACS but was subsequently transferred in this institution for further evaluation and management hence the admission. Past Medical History No previous hospitalization (+) DM – with medication-metformin (-) HPN, asthma, allergy Family History (+) HPN – maternal and paternal side (+)DM Personal and Social History 20 pack year smoker and previous alcoholic beverage drinker Review of Systems General: no weight loss, no anorexia HEENT: no blurring of vision, no tinnitus, no headache Respiratory: no cough, no colds Cardio: no chest pain, no palpitation, (+) 3 pillow orthopnea, no easy fatigability GIT: no abdominal pain, no change in bowel habit. GUT: (-) dysuria, (-) hematuria, no oliguria, no anuria Endocrine: no polyuria, no polydipsia, no polyphagia Neurologic: no seizure, LOC, no vomiting , no headache Physical Examination: Patient is conscious, coherent not in distress Vital Signs: BP: 140/90 HR: 85 RR:20 T:37 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, AB at 5th ICS AAL NRRR, no murmur ABDOMEN: flabby, NABS, soft, nontender EXTREMITIES: grossly normal no cyanosis with full equal pulse. (-) edema Assessment: Acute Coronary Syndrome prob unstable angina, high risk CAD, HCVD, Anterolateral wall Ischemia, NSR, E DM type 2 Course in the Ward: Upon admission, Patient was placed on NPO except meds. He was hooked to IVF: D5W 500mL x KVO. Diagnostics requested were 12-lead ECG q6, CBC c PC, urinalysis, CXR- PA, Troponin I quantitative, FBS, BUN, Crea, Na, K, HDL, LDL, TG, cholesterol, BUA, Mg, HbA1C, PTT, PT, 2D echo with doppler. Therapeutics given were: 1. ASA 80mg/tab, OD after lunch 2. Clopidogrel 75mg/ tab OD eventually discontinued 3. Metoprolol 50 mg/tab ½ tab BID 4. Captopril 25mg/tab TID 5. ISDN 5 mg/ tab TID and SL PRN for chest pain 6. Simvastatin 20mg/tab OD at HS 7. Diazepam 10 mg/2mL Amp ½ amp IV OD at HS 8. Nalbuphine 10mg/mL amp, ½ amp PRN IV for severe chest pain 9. Heparin 3600 u IV Bolus, then heparin 8640 u Heparin in D5W 500 mL to run for 12 hours

10. Isoket drip: D5W 90mL + Isoket 20 amp TIV 10ugtts/min 11. Furosemide drip: PNSS 40ml + 40 mg Furosemide to run for 6 cc/hr 12. Regular Insulin 5 units SQ PRn for CBG ≥250mg/dL He was also hooked to O2 support and condom catheter was also inserted On the 2nd HD, vital signs were as follows: BP120-140/80-90, CR 72-80 RR 20-22 Temp 37.1°C. There was no dyspnea, no chest pain noted but with grade 2 bipedal edema. Diet was shifted to general liquid. Additional meds given were ISDN 5 mg/tab TID nad Aldazide ½ tab OD. Transfusion of 1 u PRBC was properly typed and crossmatched was requested On the 3rd – 5th HD, vital signs were as follows: BP120-150/80-90 afebrile with normal cardiac rate but was slightly tachypneic. Diet was shifted to low salt low fat. Heparin drip was consumed then discontinued. Threadmill Stress Test was ordered on OPD basis. Captopril increased to q6 while Metoprolol to 1 tab BID. Repeat CBC with platelet and CXR was requested. Laboratory Results: X-RAY CHEST Prob CARDIOMEGALY; Pulmonary edema, AA Pneumonia not R/O ECG A-L wall ischemia Complete Blood Count Normal Values WBC 4.8-10.8 x 109 /L RBC 4.0-6.20 x 1012 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 Platelet 150-400 x 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1% PT 14.6sec Activity 76.9 INR 1.16 aPTT – 38 secs Blood Chemistry Result BUN Creatinine Sodium Potassium FBS HDL LDL 10.7 135.8 4.61 57.7 - - 50 0.64 1.98 VLDL HDL RATIO TG Cholesterol BUA Calcium Magnesium Urinalysis Aug 26 Yellow Clear Few Few Few 0-2 1-3 +3 +1 1.030 6.0 0.83 5.39 1.81 3.45 517.03 2 0.78

Aug 25 7.2 3.1 9 25.8 83.2 28 34 185 65.6 24.8 5.6 3.7 0.3

Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Cast Albumin Sugar SG pH Bacteria Calcium Oxalate


								
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